Provider Demographics
NPI:1427259175
Name:HURCOMB, NICOLE LAMBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LAMBERT
Last Name:HURCOMB
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:KRISTIN
Other - Last Name:LAMBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:51584 STATE ROAD 933
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46637-1704
Mailing Address - Country:US
Mailing Address - Phone:574-272-6575
Mailing Address - Fax:574-272-6587
Practice Address - Street 1:51584 STATE ROAD 933
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46637-1704
Practice Address - Country:US
Practice Address - Phone:574-272-6575
Practice Address - Fax:574-272-6587
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010971A122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200884210Medicaid